Journal of Pediatric Nursing 39 (2018) e1–e5

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

Insufficient Sleep Is Associated with Obesity and Excessive Screen Time

Amongst Ten-Year-Old Children in Sweden
Pernilla Garmy a,b,⁎, Eva K. Clausson a, Per Nyberg c, Ulf Jakobsson d,e
a
Department of Health Sciences, Kristianstad University, Sweden
b
Department of Health Sciences, Clinical Health Promotion Centre, Lund University, Sweden
c
Department of Health Sciences, Faculty of Medicine, Lund University, Sweden
d
Department of Clinical Sciences in Malmö, Lund University, Sweden
e
Center for Primary Health Care Research, Lund University/Region Skåne, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This study investigated sleep, television, computer habits, and obesity in school-age children.
Received 3 June 2017 Design and methods: This was a cross-sectional self-report survey of 1260 children in grade 4 (mean age, 10.1)
Revised 12 November 2017 living in southern Sweden (49.1% boys). The heights and weights of 1097 (87.1%) of the children were recorded.
Accepted 12 November 2017 Descriptive statistics, bivariate analyses, and multiple logistic regression were employed.
Results: The median length of self-reported sleep on weeknights was 9.5 h. Approximately 40% of the children re-
Keywords:
ported receiving b 9 h of sleep. The median bedtime was 9 PM (21:00). On weekends, the median bedtime was 1
Child
Computer use
h later, and they delayed getting up by 1.5 h. The median time spent watching TV and using a computer was 1 h
Obesity each. The prevalence of being overweight (including obesity) was 18%. Insufficient sleep (b9 h) was associated
Overweight with being overweight, watching TV, or using a computer for two or more hours each day, difficulty falling asleep,
Sleep and being tired at school.
Conclusions: School-age children who receive less sleep are more likely to be overweight and report excessive
television and computer use. A strong and urgent need exists to highlight the importance of healthy sleep and
media habits. It is challenging for pediatric nurses and school nurses to teach children and their families about
healthy sleep and media habits.
© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction
The number of global public health issues concerning sleep deficien-
cy, media habits, obesity, and emotional problems are increasing (Cain
& Gradisar, 2010). Parents, teachers, and pediatric nurses are confronted
with challenging questions regarding the best approach to guide chil-
dren towards a healthy lifestyle (Betz, 2014; Fogg & Johnson, 2015).
At many schools, students are provided with computers, and a signifi-
cant proportion of education is conducted using screens rather than tra-
ditional textbooks (Seomun et al., 2013). School-age children
commonly use televisions and computers as sleep aids, but these de-
vices have been shown to have the reverse effect (i.e., increased time
to fall asleep and shorter sleep duration) (Chahal, Fung, Kuhle, &
Veugelers, 2013; Eggermont & Van den Bulck, 2006). There is a link be-
tween obesity and altered sleep quality in 10-year-old children
(Pacheco et al., 2017). Many children and parents address school nurses
with questions regarding sleep and wellbeing (Garmy, Nyberg, &
⁎ Corresponding author at: Pernilla Garmy.
E-mail address: pernilla.garmy@hkr.se (P. Garmy).
Jakobsson, 2012). There is a need for more knowledge about insufficient
sleep, obesity, and screen time amongst children so that child health
professionals can provide relevant advice.
Background
Ten-year-old children are between childhood and puberty; they still
need to have a close relationship with their parents, but peers are be-
coming increasingly important. It is crucial to fit in and to be accepted
by peers. The development for children in this age can differ consider-
ably (Goswami, 2011). After the age of 10, the boys and girls start to di-
verge along different puberty trajectories that might influence sleep
(Kryger, Roth, & Dement, 2017).
Over the last century, the duration of sleep amongst children and ad-
olescents has decreased by 1 h (Matricciani, Olds, & Petkov, 2012). The
amount of sleep is associated with health-related quality of life (HRQL);
specifically, children who sleep more have a better HRQL (Gustafsson et
al., 2016). Daytime sleepiness is also associated with a lower HRQL
(Gustafsson et al., 2016). The National Sleep Foundation recommends
9 to 11 h of sleep for 6- to 13-year-olds (Hirshkowitz et al., 2015).

https://doi.org/10.1016/j.pedn.2017.11.009
0882-5963/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
e2 P. Garmy et al. / Journal of Pediatric Nursing 39 (2018) e1–e5
More than one-quarter of Swedish 11-year-olds report difficulties get-
ting to sleep more than once a week (Public Health Agency, 2014).
Insufficient sleep is associated with behavioral and cognitive deficits
(Astill, Van der Heijden, Van IJzendoorn, & Van Someren, 2012), as well
as increased frequency of being overweight (Appelhans et al., 2014;
Busto-Zapico, Amigo-Vázquez, Peña-Suárez, & Fernández-Rodríguez,
2014; Chahal et al., 2013; Danielsen, Pallesen, Stormark, Nordhus, &
Bjorvatn, 2010; Magee & Hale, 2012), and the latter is a risk factor for
metabolic disease in children (Dhuper, Buddhe, & Patel, 2013). The
World Health Organization (WHO) study entitled Health Behaviours in
School-Age Children (Inchley & Currie, 2014) found that 22% of 11-
year-olds were obese or overweight.
Associations between screen time and reduced sleep duration, as well
as between screen time and increased sleep problems, have been report-
ed (Burke, 2016; Chahal et al., 2013; Hale & Guan, 2015; Johansson,
Petrisko, & Chasens, 2016). High levels of screen time are associated
with hyperactivity/inattention problems, internalizing problems, im-
paired well-being, and a lower quality of life (Suchert, Hanewinkel, &
Isensee, 2015). Approximately 50% of 11-year-old boys use a computer
for e-mail, to access the Internet or for homework for two or more
hours on weekdays. These figures are lower amongst girls. Furthermore,
approximately two-thirds of boys play games on a computer or console
for two or more hours each day (Inchley & Currie, 2014).
Thus, the global trend shows that children's sleep time is decreasing
(Matricciani et al., 2012; Norell-Clarke & Hagquist, 2017), whilst screen
time and obesity are increasing (Inchley & Currie, 2014). To develop
child health care interventions, there is a need to investigate and docu-
ment the current status of childhood sleep, screen time, and obesity. The
current study investigated the sleep, television/computer habits, and
obesity of school-aged children in Sweden.
Methods
Participants and Setting
This cross-sectional study included children in grade 4 (mean age ±
standard deviation [SD]: 10.1 ± 0.39 years). Guardians/parents provid-
ed written informed consent for their children to answer a question-
naire regarding sleep and lifestyle; child height and weight were also
measured. The inclusion criteria were all students in grade 4 during
the 2011–2012 and 2012–2013 academic years in a municipality of
southern Sweden with approximately 110,000 inhabitants. The school
nurse gave the students the questionnaire and written information
about the study at school. The students were instructed to give the
forms to their parents/guardians. The students completed the question-
naire with a pen and paper at home. Of 2308 total students, 1260
(54.6%) returned the signed consent form and a completed question-
naire (49.1% boys); 1097 had their height and weight measured. The
drop-out analysis showed no differences regarding age (p = 0.427) or
gender (p = 0.728) for those not having their height and weight mea-
sured. Most of the missing height and weight measurements came
from one school (p b 0.001). This was because of limited access to school
nursing resources at this school at the time of the study. At the time of
the study, approximately 18% of the city's population was born in coun-
tries other than Sweden. The unemployment rate in the city was 4%, and
approximately 2% of the population received financial help from the
government. Nearly 6% of the adult population had only a compulsory
education, 25% had education at secondary level, and 67% held a post-
secondary education. Approximately 82% of the students in the munic-
ipality had parents who lived together (Statistics Sweden, 2012). The
Regional Ethical Review Board in Lund approved this study (2011/330).
Instrument
The questionnaire regarding the sleep and media habits of school-
aged children had been previously tested with regards to this age
group. Its reliability and validity were satisfactory (Garmy, Jakobsson,
& Nyberg, 2012). The reliability test-retest showed high levels of agree-
ment for bedtimes (90.4%) and length of sleep (86.8%) (Garmy,
Jakobsson, et al.,2012). The questions addressed the time when the
child typically began to get ready for bed, when they went to bed, and
the length of sleep achieved on weeknights and weekends. The ques-
tionnaire also included questions regarding how much the children
enjoyed school (very much, fairly well or not very much), feelings of
being tired at school (every day, often, seldom or never), sleeping diffi-
culties (every day, often, seldom or never), and difficulties with waking
up (every day, often, seldom or never), as well as questions about hav-
ing a bedroom television (yes or no) and time spent watching television
or using the computer (in hours and minutes).
Trained school nurses measured the heights and weights of the stu-
dents. The students wore light clothing, and the weight was measured
to the nearest 0.1 kg on an annually calibrated standard digital scale.
Student height without shoes was measured to the nearest 0.1 cm
using a manual height board. The body mass index (BMI; kg/m2) was
also calculated. Because children have a dynamic average BMI due to
their growth curves, the international age and gender-specific BMI
cut-off points for children were used to define overweight and obesity
(Cole, Bellizzi, Flegal, & Dietz, 2000). BMIs above percentile values
corresponding to an adult BMI of 25 kg/m2 were classified as
overweight; BMIs corresponding to 30 kg/m2 or higher were classified
as obese.
Data Analyses
Descriptive statistics were represented as medians and the inter-
quartile range and as percentages in the case of categorical variables.
The children were divided into two groups: those with insufficient
sleep (b9 h) according to the recommendation of the National Sleep
Foundation (Hirshkowitz et al., 2015) and those sleeping 9 h or more.
The cut-off point for time spent at the computer or watching television
was 2 h in line with the recommendation from the American Academy
of Pediatrics (Bar-On et al., 2001).
Bivariate analyses using the chi-square test were conducted to in-
vestigate the differences between boys and girls, as well as between
those with and without sufficient sleep. The factors identified from the
bivariate analyses as associated with less sleep (p b 0.05) were analyzed
in a multiple logistic regression. The Hosmer and Lemeshow goodness-
of-fit test, as well as the Nagelkerke R2 test, were used to evaluate the
quality of the regression model (Norman & Streiner, 2008). P-values
b0.05 were considered significant. All analyses were performed using
IBM SPSS version 23.0.
Results
Sleep Habits
Approximately 40% of the 10-year-old children reported insufficient
sleep (i.e., b9 h) (Table 1). The median length of sleep on weeknights
was 9.5 h compared with 10 h on weekends. The median bedtime was
9 PM (21:00), and sleep preparation occurred an hour earlier. On the
weekends, the median bedtime was delayed by 1 h compared with
weekdays, and there was a 1.5 h delay in rising.
Media Habits
The median times for watching TV and using computers were 1 h
each. Almost one in four 10-year-olds had a bedroom TV, and 28%
spent at least 2 h each day watching TV, whilst 17% spent two or more
hours in front of a computer (Table 1).
 P. Garmy et al. / Journal of Pediatric Nursing 39 (2018) e1–e5 e3

Table 1 Table 3
Length of sleep, television and computer habits, feeling tired, enjoyment of school, and dif- The factors associated with insufficient sleep (b9 h) amongst 10-year-olds (n = 1075) ac-
ficulties falling asleep and waking up amongst 10-year-olds. cording to a logistic regression analysis.

School grade 4 (mean age ± SD: Variables Odds 95% CIs for p-values
10.1 ± 0.39 years) n = 1260 ratio OR

Insufficient sleep (b9 h), n (%) 505 (40.1%) Spending ≥2 h watching TV 1.61 1.22–2.13 0.001
Median length of sleep on school days, hours 9.5 (1.0) Spending ≥2 h on a computer 2.04 1.47–2.85 b0.001
(IQR) Difficulty falling asleep (often/every day) 2.35 1.63–3.40 b0.001
Median length of sleep on weekends, hours 10.0 (1.0) Feeling tired at school (often/every day) 1.87 1.24–2.84 0.003
(IQR) N1.5 h difference between getting up on school 1.45 1.12–1.87 0.005
Median time getting ready for bed (IQR) 8 PM (60 min) days and weekends
Median bedtime on school days (IQR) 9 PM (30 min) Overweight/obese 1.72 1.24–2.40 0.001
Median time getting up on school days (IQR) 7 AM (15 min) 2
Hosmer and Lemeshow goodness-of-fit test, p = 0.301; Nagelkerke R = 0.111. Missing
Median bedtime on weekends (IQR) 10 PM (60 min)
cases: n = 185.
Median time getting up on weekends (IQR) 8:30 AM (60 min)
Median difference between getting up on 1.5 (1.0)
school days and weekends, hours (IQR)
Median time watching TV, hours (IQR) 1.0 (1.0) asleep; being tired at school; N1.5 h difference between getting up
Median time on a computer, hours (IQR) 1.0 (1.0)
time on school days and weekends; and overweight/obesity.
Having TV in the bedroom, n (%) 311 (24.7%)
≥2 h watching TV each day, n (%) 348 (27.6%)
≥2 h on a computer each day, n (%) 214 (17.0%) Discussion
Difficulties falling asleep often or every night, 168 (13.3%)
n (%) Approximately 40% of the 10-year-olds reported insufficient sleep
Enjoys school very much, n (%) 890 (70.6)
(b9). This condition was associated with obesity, spending more than
Feeling tired at school often or every day, n 124 (9.8%)
(%) 2 h watching TV or being on a computer, being tired at school, and irreg-
Difficulty waking up often or every day, n (%) 415 (32.9%) ular waking patterns between school days and weekends. Other studies
Min = minutes, IQR = interquartile range. have found a link between less sleep and obesity (Appelhans et al.,
2014; Chahal et al., 2013; Kjeldsen et al., 2014; Magee & Hale, 2012).
Sleep affects our metabolic system, but families with consistent bed-
School and Sleeping Problems times and limited access to television and computers might also have
food-related boundaries regarding candy and unhealthy foods, as well
A majority (70%) of the students enjoyed school very much, but 13% as physical activity (Hirshkowitz et al., 2015). There might also be a so-
often had difficulties falling asleep. Ten percent reported that they were cioeconomic factor not considered here.
often tired at school, and one-third often had difficulties waking up The length of sleep amongst children and adolescents has decreased
(Table 1). by approximately an hour over the last hundred years (Matricciani et al.,
2012). The current findings regarding the length of sleep, bedtime, and
time spent watching TV and using a computer were consistent with
Overweight and Obesity studies conducted 3 and 4 years earlier (Garmy, 2011; Garmy, Nyberg,
et al., 2012).
The prevalence of being overweight (including obesity) was approx- The prevalence of being overweight was 18% in the current study;
imately 18%, and the prevalence of obesity alone was 3% (Table 2). this statistic is comparable with the 22% observed amongst 11-year-
olds in the WHO study entitled Health Behaviours in School-Age Children
Gender Differences (Inchley & Currie, 2014). Health promotion with regard to overweight
children is a challenging task for child health professionals in school
Boys spent more time at a computer than girls (p b 0.001). Girls and health settings.
more frequently reported difficulties waking up (p b 0.001). Girls also One important future research aim might concern how to combine a
reported more irregular sleeping habits between school days and on reasonable amount of media use with a healthy lifestyle. Children and
the weekend. It was more common for girls to get up from bed N1.5 h adults must learn how to use electronic devices wisely. The availability
later on weekends compared with school days (p b 0.001). No other of new media offers great opportunities, as well as many challenges
gender differences were found. (Nuutinen, Ray, & Roos, 2013; Rafla, Carson, & DeJong, 2014). Todd et
al. (2008) found positive effects with regard to a family-centered inter-
vention on reducing electronic media use, which increased physical ac-
Factors Associated with Insufficient Sleep tivity and improved dietary behaviors in 8- to 11-year-old boys. One
lesson learned from that study was the importance of child health pro-
The factors identified from the bivariate analyses to be associated fessionals with regard to involving and motivating both the child and
with less sleep (p b 0.05) were analyzed in a logistic regression analysis their family members in the intervention. An interesting topic for po-
(Table 3). Insufficient sleep (b 9 h) was associated with two more hours tential future studies would be the children and adolescents who go to
of watching TV and/or using a computer each day; difficulty falling school, come home and do their homework, spend 2 h playing or chat-
ting on the Internet, and then go to bed at a reasonable time. One
Table 2 salutogenic research question would be to investigate their strategies
Rates of overweight and obesity amongst 10-year-olds⁎. in maintaining a healthy lifestyle with a reasonable amount of screen
School grade 4 (mean age ± SD: 10.1 ± 0.35 time.
years), n = 1097

Overweight (obesity 194 (17.7%) Limitations

included), n (%)
Obesity, n (%) 28 (2.6%) One strength of the current study is that it was distributed amongst
⁎ Overweight and obesity were calculated using the international age and gender-spe- participating schools across one municipality in Sweden (i.e., one city
cific BMI cut-off points for children (Cole et al., 2000). Missing cases: n = 163. and its rural surroundings). Moreover, trained school nurses measured
e4 P. Garmy et al. / Journal of Pediatric Nursing 39 (2018) e1–e5
all of the children, and the questionnaire used in this study was previ-
ously tested and found to be reliable and valid (Garmy, Nyberg, et al.,
2012). The response rate was 54.6%, and failure analysis showed that,
for gender or geographical location within the city, students who did
not return the questionnaire did not significantly differ from those
who did. Self-reported sleep durations are sufficiently reliable
(Martinez et al., 2014), but more objective measures might be even
more reliable.
Implications for Nursing Practice
Our findings reinforce the importance of school-aged children ac-
quiring their recommended 9–11 h of sleep (Hirshkowitz et al., 2015).
Sleep duration is reduced by the use of electronic devices such as
smartphones, computers, and other screens. When used wisely, these
electronic devices can promote learning, wellbeing, and friendship;
however, retaining the positive sides of media use whilst limiting the
harmful effects is challenging. One practical suggestion is to keep the
bedroom free from screens, including smartphones (Burke, 2016;
Garmy & Ward, 2017; Johansson et al., 2016). Pediatric nurses meet
with school-aged children and their parents in various healthcare set-
tings, and school nurses are a valuable resource for schools. Discussions
with children should be conducted at individual health visits or in group
discussions in the classroom with the school nurse as moderator. School
nurses and other child healthcare providers are also often welcome
speakers or moderators in parental meetings at school (Garmy, 2013).
Pediatric nurses can recommend successful interventions regarding
obesity prevention (Gruenfeld, Zagarins, Walker, & Skinner, 2013;
Jang, Chao, & Whittemore, 2015; Tucker et al., 2013) and sleep educa-
tion (Fenton, Marvicsin, & Danford, 2014).
Conclusions
Less sleep in children was associated with unfavorable factors such
as being overweight and excessive television viewing and computer
use. A strong and urgent need exists to highlight the importance of
sleep and media habits. It is a challenge for pediatric nurses who work
in school healthcare or other health settings to teach children and
their families about healthy sleep and media habits.
Acknowledgments
We warmly thank all of the participating students and school nurses
for their kind efforts in connection with this study.
Human Subjects Approval Statement
The Regional Ethical Review Board in Lund approved this research
(2011/330).
Funding
Södra Sveriges Sjuksköterskehem SSSH, the Queen Silvia Jubilee
Fund, the Swedish Insurance Society, the Ebba Danelius Foundation of
the Swedish Society of Nursing, the Kempe-Carlgrenska Foundation,
Clas Groschinskys Memorial Fund, and the Swedish Sleep Research So-
ciety supported this work.
Declaration of Conflicting Interests
The authors have no conflicts of interest to declare.
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